Living donor psychosocial assesment/follow-up practices in the partners' countries of the ELIPSY project.

BACKGROUND: Living donor (LD) transplantation has increased recently, but psychosocial aspects of living donation have not been well characterized, as risk factors for the donors. ELIPSY is a project confunded by EAHC, seeking to develop a common methodology for all EU countries for LD assessment/follow-up in the psychosocial sphere (www.eulivingdonor.eu). OBJECTIVE: To evaluate current psychosocial LD assessment/follow-up practices among European centers for key aspects and differences between kidney and liver programs. METHODS: Within a timeline of 30 months, this phase of the project sought to identify current LD psychosocial assessment/follow-up practices. The final survey concerned two versions focused on the kidney and on liver transplant program. The survey took place in ELIPSY partner centers under their own responsibility. Each of the centers sent the survey to other ones performing LD in their country. Partners in the EULID project includes ones in the United Kingdom, Poland, and Romania. The results were analyzed separately for each program seeking to compare and define differences among them. RESULTS: The survey took place in 10 European countries including 65 centers with LD programs. Positive answers regarding psychosocial assessment/follow-up practices were obtained for 26 (42%) kidney and nine (38%) liver centers. Some centers perform several psychosocial follow-ups but did not explain their tools, whereas the centers that did explain the tools used the same ones for both programs.

Kidney transplantation--a 46-year experience from the Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.

The limiting factor in organ transplantation is the availability of organs. Ongoing work to improve donation rates both at the public and the organizational level in donating hospitals is essential. We also think that encouragement of live donation is important, and the possibility of ABO incompatible transplantation has increased the number of LD transplantations. The one-year graft survival rate is excellent and focus has shifted towards achieving long-term results to reduce the attrition rate. There is also an increasing interest in studying and working to reduce comorbidities on a long-term basis and thus, improve survival rates and recipient quality of life.

Long-term follow-up of living liver donors.

OBJECTIVES: At our center living donor liver transplantation (LDLT) represents 4% of all transplantations. The aim of this cross-sectional study was to clarify the current well-being of the donors, their experiences of being a donor, as well as the regenerative capacity of the liver. PATIENTS AND METHOD: Thirty-six healthy subjects donated a part of their liver between 1996 and 2007. Thirty-four patients participated in the study and completed our questionnaire. We performed magnetic resonance imaging (MRI) of the liver, physical examination, and blood chemistry. RESULTS: Twenty-three subjects had donated the left lateral segment and 11 the right lobe. Their hospital stay ranged from 5-15 days (median, 10). Mostly, the sick-leave period was 8-12 weeks and time for recovery was 3-6 months. Long-term problems were heartburn, abdominal discomfort, incisional hernia, and fatigue. Twenty-six (76.5%) subjects viewed the donation experience as entirely positive; no one was regretful. Liver function tests were normal. The MRI data at follow-up of 13 left lateral segment and 11 right lobe grafts showed recovery of the total liver volume to almost preoperative values, mean 1522 ± 241 mL versus 1552 ± 219 mL, respectively. CONCLUSION: Living liver donors commonly recovered after 3-6 months, perceiving donation as a positive experience with no regret. Durable side effects were mainly heartburn and abdominal discomfort, but the symptoms were mostly mild. Liver function was normal. The MRI data showed a mean regeneration of liver volume to 98.6% of the preoperative values.

Single or double arteries in the remnant kidney after donation: influence on the long-term outcome of the donor.

BACKGROUND: A kidney with a single artery is preferred for donation. We wondered how often the donor is left with double or triple arteries, and whether this has any implications for long-term kidney function. METHODS: The consecutive living donors from 1984 to 1988 were reevaluated for kidney function and outcome. RESULTS: In total, 154 donor nephrectomies were performed with an open anterior technique. Ninety-eight patients were left with a single artery to the remnant kidney and 56 (36%) with more than one. Six individuals were left with 3 arteries. The mean age at donation was 48 +/- 12 years and mean age at reevaluation was 68 +/- SD 12 years. In the group with a remnant single artery, the mean preoperative serum creatinine level was 87 +/- 11 micromol/L, at 6 months it was 127 +/- 20 micromol/L, and in 2007 it was 90 +/- SD 23 micromol/L. The estimated glomerular filtration rate (GFR) was 67 +/- 18 mL/min. Thirty-three percent of donors (19/58) had developed hypertension. Among the group with multiple remnant arteries, the mean preoperative serum creatinine level was 87 +/- SD 11 micromol/L, at 6 months it was 131 +/- 21 micromol/L, and in 2007 it was 100 +/- 45 micromol/L. Estimated GFR was 64 +/- 16) mL/min. Twenty-eight percent of the donors (10/36) had developed hypertension. CONCLUSIONS: One third of kidney donors were left with double or triple arteries to the remnant kidney. The 20-year follow-up showed no significant difference in the renal function between the 2 groups.

Living kidney donors developing end-stage renal disease.

The incidence of end-stage kidney failure (ESRF) was analyzed among the cohort of 1112 living kidney donors who underwent nephrectomy from 1965 through 2005. It was found that at least six persons had developed ESRF at 14 to 27 years (median = 20 years), following donation. Five of six were men. Five were parents and one, a sibling. The diagnoses were nephrosclerosis (n = 4), postrenal failure (n = 1), and renal carcinoma (n = 1). One donor, aged 45 years, underwent kidney transplantation.

Living donor kidney transplantation.

Living donor kidney transplantation is the optimum treatment for the uremic patient. Successful kidney transplantations started in 1953 in Boston and in Sweden in 1964. This article showed data on the selection of the donor, surgical techniques for the removal of the kidney, and follow-up of short-term complications. The long-term results included the number of donors who developed hypertension and the few donors who developed end-stage renal failure (ESRF) and the reasons for this. Finally, new groups of donors such as blood group-incompatible donors and anonymous donors have been accepted, each of whom have their own programs. This article also discussed our responsibilities as renal specialists or transplant surgeons for kidney donors at surgery and postsurgery.

Phenotypic expression of factor H mutations in patients with atypical hemolytic uremic syndrome.

We investigated the phenotypic expression of factor H mutations in two patients with atypical hemolytic uremic syndrome (HUS). Factor H in serum was assayed by rocket immunoelectrophoresis, immunoblotting, and double immunodiffusion and in tissue by immunohistochemistry. Functional activity was analyzed by hemolysis of sheep erythrocytes and binding to endothelial cells. A homozygous mutation in complement control protein (CCP) domain 10 of factor H was identified in an adult man who first developed membranoproliferative glomerulonephritis and later HUS. C3 levels were very low. The patient had undetectable factor H levels in serum and a weak factor H 150 kDa band. Double immunodiffusion showed partial antigenic identity with factor H in normal serum owing to the presence of factor H-like protein 1. Strong specific labeling for factor H was detected in glomerular endothelium, mesangium and in glomerular and tubular epithelium as well as in bone marrow cells. A heterozygous mutation in CCP 20 of factor H was found in a girl with HUS. C3 levels were moderately decreased at onset. Factor H levels were normal and a normal 150 kDa band was present. Double immunodiffusion showed antigenic identity with normal factor H. Factor H labeling was minimal in the renal cortex. Factor H dysfunction was demonstrated by increased sheep erythrocyte hemolysis and decreased binding to endothelial cells. In summary, two different factor H mutations associated with HUS were examined: in one, factor H accumulated in cells, and in the other, membrane binding was reduced.

No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up.

BACKGROUND: There is a lack of kidneys available for kidney transplantation, and living donors are increasingly used. It is important to examine the possible long-term adverse affect on the renal function and blood pressure of the donors. METHODS: We have made a comprehensive follow-up of all living kidney donors at our center from 1964 to 1995. Of 402 donors still alive, we were able to get information about serum creatinine, urinary proteins, and blood cells in urine using reagent strips, and blood pressure from 87%. The glomerular filtration rate (GFR) was estimated using a formula and was measured with Iohexol clearance in 43 of the donors. Individual data on GFR and the prevalence of hypertension were compared with the age- and gender-expected values. RESULTS: The mean age of the examined donors was 61 years (SD:13) at follow-up, and the time since donation was 12 years (SD:8). The average estimated GFR was 72% (SD:18) of the age-predicted value. The ratio of the estimated to the predicted GFR showed no correlation to the time since donation, indicating that there is no accelerated loss of renal function after donation. GFR below 30 ml/min was found in five donors. No donor died in uremia or had dialysis treatment before death. However, three donors developed renal disease, and one was in dialysis treatment. In two of these cases, hereditary factors were possibly involved. Hypertension was present in 38% of the donors but the age-adjusted prevalence of hypertension among donors was not higher than in the general population. Significant proteinuria (> or =1.0 g/L) was found in 3% and slight proteinuria (<1.0 g/L) in 9% of the donors. Proteinuria was associated with hypertension and a lower GFR. CONCLUSIONS: On average, the remaining renal function of kidney donors did not deteriorate more rapidly than what may be expected from ageing. However one-third of the female and half of the male donors developed hypertension and, approximately, 10% displayed proteinuria. Nevertheless, our study supports the continued use of living kidney donors if strict criteria are used for acceptance.

Kidney donors don't regret: follow-up of 370 donors in Stockholm since 1964.

BACKGROUND: The aim of the study was to present the views of our kidney donors since 1964, at the time of donation, as well as later on--and to assess their current subjective health. METHODS: A total of 451 living-donor nephrectomies were performed on Swedish residents in Stockholm from April 1964 until the end of 1995. A questionnaire with 11 questions about the donation and a standardized health form (SF-36) were sent to all donors alive in 1997 (n=403). RESULTS: The mean age (+/-SD) of the donors was 61+/-14 years at follow-up and the time-since-donation was 12.5+/-7.7 years. The response rate was very good (92%). Current health, as assessed by form SF-36, was satisfactory. Donors scored somewhat better than those reported in a random sample of the Swedish population. The decision to donate had been easy: 86% made the decision themselves, without being pushed. Twenty-three percent thought that the nephrectomy had been troublesome. A higher percentage of young donors had felt that the postoperative period was difficult. Most donors (56%) stated that it had taken more than 2 months before they returned to a "normal" life, and 5% felt that they never completely recovered. Less than 1% of the donors regretted the donation. The commonest current medical prescription was antihypertensives (15%). The actual mean serum creatinine was 103+/-22 (range 48-219) micromol/L. CONCLUSIONS: The results indicate that the degree of health is at least as high as in the general population. The decision to donate was easy for most of the donors, but surgery and the recovery period were troublesome and lasted longer than expected. Kidney function was acceptable.

[An example of successful systematic improvement work. Process management improved routines and simplified dialysis starts]. / Lyckat exempel på systematiskt förbättringsarbete. Processledning förbättrade rutiner och förenklade dialysstarter.

In the care of patients with end-stage renal disease in need of dialysis at our hospital we found that only 50 per cent of the 199 patients who started hemodialysis during 1995-96 had a functioning vascular access, predominantly in the form of a matured arteriovenous fistula. Although these findings were presented at departmental meetings and improvement was deemed essential, the situation persisted according to a new survey in 1998. The problem was therefore selected for an improvement project within the framework of process management. Through root cause analysis with data collection and subsequent application of the Plan-Do-Study-Act cycle, a team demonstrated that the cause was not, as previously believed, delays in bringing these patients to surgery. Instead it stemmed from a lack of consensus about when to initiate preparations for dialysis, and from insufficient analysis of how patients' renal function declined over time. Therefore the decision to prepare for dialysis was generally made far too late. With new guidelines for determining when to start preparations (at a renal creatinine clearance of 15-20 ml/min), provision of a diagram-sheet for plotting 1/S-creatinine in each patient's file (to facilitate monitoring of the decline in renal function over time), and continuous feedback to department physicians on performance, the proportion of patients who started hemodialysis with a proper access approached 100 per cent.

Kidney donors live longer.

BACKGROUND: A very important issue in living kidney donor transplantation is whether the donation is safe for the donor. The aim of this study was to examine survival and causes of death in kidney donors and to assess the renal function in those who had donated a kidney more than 20 years ago. METHODS: A total of 459 living donor nephrectomies were performed in Stockholm from 1964 until the end of 1994. By using national registers, all 430 donors living in Sweden were traced. Donor survival was analysed using the Kaplan-Meier method. Expected survival was computed using the Hakulinens method and was based on national mortality rates. RESULTS: Forty-one subjects had died between 15 months and 31 years after the donation. The mortality pattern was similar to that in the general population, the majority dying of cardiovascular diseases and malignancies. After 20 years of follow-up, 85% of the donors were alive, whereas the expected survival rate was 66%. Survival was thus 29% better in the donor group. One third of the donors (aged 46-91 years) who had donated >20 years ago had hypertension. There was a deterioration in the renal function with increasing age, similar to what is seen among normal healthy subjects. The average glomerular filtration rate in donors aged 75 years and over was 48 ml/min/1.73 m2. CONCLUSIONS: To donate a kidney does not seem to constitute any long-term risk. The better survival among donors is probably due to the fact that only healthy persons are accepted for living kidney donation.

Reasons for not accepting living kidney donors.

Organs were donated by a small number of relatives (54/146=37%), genetically related or familial, who volunteered to give a kidney to a relative or spouse at our institution in 1991-1994. The most common reason for not accepting them was an immunological incompatibility (30 cases), followed by a diagnosis of hypertension and/or renal disease (24 cases). Other medical contraindications-including heart/lung disease, obesity, latent diabetes, and hepatic disease-were found in 14 potential donors. One woman (22 years of age) was judged too young for donation. Five ESRD patients died before the investigation of the donor had been completed. Eighteen potential donors changed their minds and decided not to donate a kidney. Interestingly, there was a high percentage of denial of spouses due to positive crossmatches.

Increased prevalence of atherosclerotic wall changes in patients with hyperlipidaemia after renal transplantation.

OBJECTIVES: The initial aim of this study was to evaluate the possibility of influencing atherosclerosis in hyperlipidaemic renal transplant patients by lowering blood lipids with gemfibrozil treatment. DESIGN: Although this double-blind, randomized trial was stopped after 6 months owing to the suspicion of drug interference, we report here on the results of baseline ultrasonographic examinations. SETTING: The outpatient clinic at the Department of Transplantation Surgery, Huddinge University Hospital, Huddinge, Sweden. SUBJECTS AND METHODS: The carotid arteries were examined in 16 out of the 19 kidney transplant patients included in the study using an ultrasonographic duplex scanner. MAIN OUTCOME MEASURES: Plaque occurrence and the common carotid intima-media thickness of the renal transplant recipients were compared to the same parameters in a normotensive control group of approximately the same age from a previous study. RESULTS: An increased prevalence of plaque (75% of the patients having plaque on one or both sides) was seen in the hyperlipidaemic renal transplant patients in comparison with the control group (16%; P < 0.001). The common carotid intima-media complex was thicker (P < 0.05), and the lumen diameter and the calculated cross-sectional intima-media area were greater (P < 0.01-0.001) in the transplant recipients. CONCLUSIONS: Markedly increased atherosclerotic wall changes are seen in the carotid arteries of patients with hyperlipidaemia after renal transplantation.

Antibodies in alloimmunized uraemic patients treated with recombinant erythropoietin.

We have retrospectively analysed sera from 52 already sensitized uraemic patients collected over 1 year and compared erythropoietin (EPO)-treated with non-EPO-treated patients. Significantly fewer (P<0.01) patients (33%) on dialysis because of the rejection of their kidney grafts received EPO than patients on dialysis because of underlying kidney disease (71%). EPO treatment reduced the number of additional blood transfusions, since 3/28 EPO-treated but 12/24 non-EPO-treated patients were given blood (P<0.05). Among the EPO-treated patients, 64% showed a loss of panel-reactive antibodies (PRA), as measured by the micro-lymphocytotoxic technique, while only 12.5% of the non-treated patients showed a loss of PRA (P<0.01). In the subgroup of transplanted patients, PRA loss was only found among the EPO-treated patients, but their number was small (P<0.05). The class, subclass and specificities of the antibodies, as determined by FACS (flow cytometry) analyses, showed no distinct differences between EPO- and non-EPO-treated patients. The differences were significant between transfused and previously transplanted patients.